Citation Nr: 1539572 Decision Date: 09/15/15 Archive Date: 09/24/15 DOCKET NO. 12-30 826A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Cheri D. Smith, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1969 to March 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office in Waco, Texas. In a September 2014 decision, the Board denied the claim for service connection for ED to include as secondary to service-connected PTSD. The Veteran appealed the Board's September 2014 decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2015 Order, the Court granted a Joint Motion of the parties to vacate the Board's decision and remanded the case to the Board for action consistent with the terms of the Joint Motion. The Board has reviewed the Veteran's physical claims files as well as the record maintained in the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran is seeking service connection for erectile dysfunction that he contends is secondary to his service-connected PTSD. As indicated above, the Court granted the parties' Joint Motion for Remand, in which the parties agreed that the Board's September 2014 decision failed to address whether the Veteran's service-connected PTSD, as opposed to any medications prescribed for it, caused or aggravated his ED. In this regard, a December 2010 treatment record noted that the Veteran indicated that his ED coincided with the onset of his PTSD symptoms. In the same note, the Veteran also indicated that he had experienced ED symptoms since leaving Vietnam. In addition, the parties noted that an August 2011 VA examination was deficient because the examiner did not evaluate all of the Veteran's PTSD medications to determine whether those medications were the potential cause or aggravator of his ED. In the August 2011 VA examination report, the examiner opined that two of the Veteran's PTSD medications, Elavil (Amitriptyline) and Aprazolam (Xanax), were likely not the cause of his ED. Instead, the examiner opined that the Veteran's other health issues, such as hypertension, nephrotic syndrome, history of respiratory and renal failure, and pericardial effusion were likely the cause of his ED. In support of this opinion, the examiner noted that both Harrison's Principle of Medicine and the Physician's Desk Reference did not contribute ED to either Elavil or Alprazolam. However, as noted by the parties to the Joint Motion, the August 2011 VA examiner failed to consider all medications, not just Elavil and Aprazolam, that the Veteran has been prescribed to treat his service-connected PTSD. In particular, the Board notes that VA medical records indicate that the Veteran has also been prescribed Prozac (Fluoxetine), Zoloft (Sertraline), Paxil (Paroxetine), Celexa (Citalopram), Neurontin (Gabapentin), Effexor (Venlafaxine HCL), Wellbutrin (Bupropion), Trazodone, Cymbalta (Duloxetine HCL), Seroquel (Quetiapine Fumarate), Lamictal (Lamotrigine), Paxil (Paroxetine), Klonopin (Clonazepam), Serzone (Nefazodone), Tofranil (Imipramine), Lithium, Depakote, Ativan (Lorazepam) for the treatment of his PTSD. 1 Thus, the Board must remand this matter for an additional medical opinion that addresses whether the Veteran's ED is related to service or is caused or aggravated by the Veteran's service-connected PTSD, to include any medication that has been prescribed to treat his service-connected PTSD. Also, the claims file currently includes VA medical center (VAMC) treatment records dated through August 2011. Dunn v. West, 11 Vet. App. 462 (1998); Bell v. Derwinski, 2 Vet. App. 611 (1992). Therefore, on remand, the RO should obtain and associate with the claims file all outstanding, pertinent VAMC records dated from August 2011 to the present. Accordingly, the case is REMANDED for the following actions: 1. Obtain all outstanding VAMC records from August 2011 to the present. All such available documents should be associated with the claims folder or Virtual VA/VBMS folders (as appropriate). 2. Then, schedule the Veteran for a new VA examination to determine the nature and etiology of the Veteran's ED. The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner, and the report should include discussion of the Veteran's documented medical history and assertions. All indicated tests should be accomplished and all clinical findings should be reported in detail. The examiner should reconcile the August 2011 examiner's opinion. (a) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's ED is related to service. In rendering this opinion, the examiner must consider the Veteran's statements regarding the onset and statements regarding the continuity of symptomatology. (b) The examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability), that the Veteran's ED is caused by his service-connected PTSD, to include any medications prescribed to treat his PTSD (to include, but not limited to: Prozac (Fluoxetine), Zoloft (Sertraline), Paxil (Paroxetine), Celexa (Citalopram), Neurontin (Gabapentin), Effexor (Venlafaxine HCL), Wellbutrin (Bupropion), Trazodone, Cymbalta (Duloxetine HCL), Seroquel (Quetiapine Fumarate), Lamictal (Lamotrigine), Paxil (Paroxetine), Klonopin (Clonazepam), Serzone (Nefazodone), Tofranil (Imipramine), Lithium, Depakote, Ativan (Lorazepam)). (c) The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's ED is aggravated (permanently worsened beyond the natural progress of the disorder) by his service-connected PTSD, to include any medications prescribed to treat his PTSD, to include, but not limited to: Prozac (Fluoxetine), Zoloft (Sertraline), Paxil (Paroxetine), Celexa (Citalopram), Neurontin (Gabapentin), Effexor (Venlafaxine HCL), Wellbutrin (Bupropion), Trazodone, Cymbalta (Duloxetine HCL), Seroquel (Quetiapine Fumarate), Lamictal (Lamotrigine), Paxil (Paroxetine), Klonopin (Clonazepam), Serzone (Nefazodone), Tofranil (Imipramine), Lithium, Depakote, Ativan (Lorazepam)). If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it. The examiner should set forth all examination findings, together with the complete rationale for all conclusions reached. 3. After ensuring compliance with the remand instructions, readjudicate the claim on appeal. If the benefit sought on appeal remains denied, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015). 1 A thorough review of the medical records associated with this claim reveal that the medications prescribed to the Veteran for PTSD have been referred to at times by both the brand name, and the generic name. Hence, for clarity sake the Board will refer to both names where appropriate. --------------- ------------------------------------------------------------ --------------- ------------------------------------------------------------